| Abstract: | 在現行台灣全民健康保險的制度下，門診醫療至少有三大特色：平均就診次數高，就診於醫院（特別是醫學中心）的次數高，更換醫師與醫療院所頻繁。「逛醫院」有其社會文化與醫療制度的背景，應是目前台灣（或非西方先進國家）的特有現象。民眾非必要地常逛醫院，固然反映出其醫療需求尚未為現有制度所滿足，卻也易使得現有制度的運作效率大打折扣，亦會增加個人的機會成本與暴露於不必要的醫療風險，不僅有其總體健保財務意義，也是醫療制度管理改革的一大課題，值得研究。本研究計畫擬利用國家衛生研究院全民健康保險研究資料庫的檔案，運用資料探勘的技術，量化分析台灣地區民眾門診醫療的「逛醫院」現象。分析的面向將包括：病人人口學特性、醫療院所特性、醫師特性、疾病診斷、藥品品項、檢查檢驗項目等。近十年來，資料探勘主要運用於鉅量電子數據資料的分析上，其技術有別於傳統的統計分析，常見的技術包括frequent patterns, association rules, classification, cluster analysis, sequence analysis, social network analysis等，值得嘗試運用於全民健康保險研究資料庫龐大資料的分析上。台灣全民健康保險十餘年來的經驗，若能廣泛且縝密地分析，將有助於我國醫務管理研究學門的發展。深信以本研究計畫團隊過往的學術發表經歷，應能在此申請課題有深入且持續的國際論文發表。
逛醫院與多重用藥的關係：台灣地區研究目的：台灣全民健康保險制度有幾大特色：（一）病人可自由選擇醫師與醫療機構就診，無需正式轉診；（二）藥品給付寬鬆；（三）部分負擔額度低。是以，全民健康保險保險對象常見就診頻繁、更換醫師頻繁與每張處方的藥品數高等情形。民眾更換醫師頻繁與多重用藥的關係，值得瞭解。方法：研究資料來自國家衛生研究院全民健康保險研究資料庫200,000人抽樣歸戶檔在2005年的資料。分析侷限於因慢性病就診的門診記錄，慢性病就診的操作定義為有大於七天用藥處方的門診就診。對於一年內曾有慢性病就診的保險對象，計算其曾就診醫療院所的總數與其於一年內領取慢性病用藥的不同藥品總數，進一步計算兩者的相關情形。結果：在檔案中，56,956人（30,070名女性、26,886名男性；平均年齡49.9 ± 19.9歲）於2005年裡曾有因慢性病就診。這些病人一年裡平均有7.3 ± 7.3 (max. 98) 慢性病就診，造訪1.5 ± 0.9 (max. 32) 家醫療院所，領取7.3 ± 7.3 (max. 93) 不同的慢性病用藥品項。就診醫療院所的總數與不同的慢性病用藥總品項數間有強烈相關(Spearman‘s rho 0.548, p < 0.001 [2-tailed])。結論：在不同醫療院所愈多次的慢性病就診，與愈多的不同藥品品項開立有關。除了病人的因素，醫療系統內在的原因值得後續探究。Relationship of doctor shopping and polypharmacy: a nationwide study in TaiwanOBJECTIVES: The National Health Insurance (NHI) system in Taiwan is characterized by (1) free choice of physicians and health care facilities without formal referral, (2) generous drug benefits, and (3) low co-payments. The NHI beneficiaries thus exhibit features of frequent attendances, frequent changes of physicians, and a higher number of drug items in a prescription. It is interesting to know how likely a doctor shopper is to be a patient of polypharmacy. METHODS: The data sources came from the historical claims datasets of 200,000-person cohort in 2005, offered by the National Health Insurance Research Database in Taiwan. The analysis was limited to the ambulatory records with conditions of chronic diseases, represented by visits with more than 7 days of drug supply. For those people with at least one visit for chronic diseases, the degree of correlation between the total number of consulted facilities and the total number of distinct prescribed drug items in all visits for chronic diseases in 2005 would be determined. RESULTS: Of the study cohort 56,956 people (30,070 females and 26,886 males; mean age 49.9 ± 19.9 [SD] years) had at least one visit for chronic diseases in 2005. On average, one of these people had paid 6.8 ± 7.0 (max. 98) visits, consulted 1.5 ± 0.9 (max. 32) facilities, and received 7.3 ± 7.3 (max. 93) distinct drug items for chronic diseases in a year. The total number of consulted facilities for chronic diseases in a year was strongly correlated with the total number of distinct prescribed drug items in all visits for chronic diseases in a year (Spearman‘s rho 0.548, p < 0.001 [2-tailed]). CONCLUSION: More visits for chronic diseases at different facilities were related to more drugs prescribed. Besides the patients’’ reasons, the causes inherent in the health care system deserve investigations. |
